Workers' Compensation Forms

Claim Form (DWC-1)

If you are injured on the job, your employer should give you a claim form. If they haven't provided you a claim form, and you were injured on the job, then you can download the form here and fill out and mail it to your employer Certified Mail Return Receipt.

Note: We are providing this form for your convenience. We are not taking action on your claim unless we have met in person and have a mutual written agreement to represent you in your case.

Doctor Pre-Designation

This Doctor Pre-Designation Form was created by the Division of Workers' Compensation to allow an injured worker to predesignate a physician prior to an industrial injury. You can download it by clicking here. Once you fill out the form, make a copy for yourself, provide it to your employer, and note the date your provided it to them.

Medical Mileage Expenses

You are entitled to medical mileage, which includes transportation to and from the treating physician, physical therapy, and the pharmacy. Mileage forms are different depending on the year you incurred the mileage. For example, if you were injured in 2013 and you have mileage in 2013, 2014, and 2015 that you have never submitted and you desire to get paid on your back-mileage, then you would need to download a different form for each year.

This website is for information purposes only. If you are looking for legal advice, you should contact our office at 707-532-4344. We will not give advice to anyone outside of California, since we are only licensed to practice law in California.

The information that is found on this website is for California Workers' Compensation cases only. In addition, discussion surrounding CalPERs in the rural areas of Northern California. Other counties in California may have their own retirement programs and do not use CalPERS. Those counties could be different.

Filing a false or fraudulent workers' compensation claim is a felony subject to up to 5 years in prison or fine of up to $50,000 or double the value of the fraud, whichever is greater, or by both imprisonment & fine.